Tuesday, May 10, 2011

Regular blog readers will be familiar with the heated battle over a controversial proposed mental condition of "Paraphilic Coercive Disorder" for rapists. Now, the American Psychiatric Association has issued its latest draft of the DSM-5 diagnostic manual, with the condition relegated to the appendix. The proposal was favored by psychologists working for the government in Sexually Violent Predator (SVP) civil commitment cases, as it would have made it far easier to testify that sex offenders are mentally ill. It had met with strong opposition from scientists, including premier rape researcher Raymond Knight of Brandeis University.

Among other outspoken opponents was psychiatrist Allen Frances, an emeritus professor from Duke University who chaired the DSM-IV Task Force. In blog posts soon to go live at the Psychiatric Times and Psychology Today, he cautions that the battle is not over: The current attempt to place the pseudoscientific condition into the appendix of the DSM 5 as a condition warranting further study is still a mistake.

"Important message"

Dr. Frances said the rejection should send a strong message to those involved in the SVP civil commitment industry:

Dr. Allen Frances

The evaluators, prosecutors, public defenders, judges, and juries must all recognize that the act of being a rapist almost always is an indication of criminality, not of mental disorder. This now makes four DSM's (DSM III, DSM IIIR, DSM IV, DSM 5) that have unanimously rejected the concept that rape is a mental illness. Rapists need to receive longer prison sentences, not psychiatric hospitalizations that are constitutionally quite questionable.

This DSM 5 rejection has huge consequences both for forensic psychiatry and for the legal system. If "coercive paraphilia" had been included as a mental disorder in DSM 5, rapists would be routinely subject to involuntary psychiatric commitment once their prison sentence had been completed. While such continued psychiatric incarceration makes sense from a public safety standpoint, misusing psychiatric diagnosis has grave risks that greatly outweigh the gain…. Preventive psychiatric detention is a slippery slope with possibly disastrous future consequences for both psychiatry and the law. If we ignore the civil rights of rapists today, we risk someday following the lead of other countries in abusing psychiatric commitment to punish political dissent and suppress individual difference.

This DSM 5 rejection of rape as mental disorder will hopefully call attention to, and further undercut, the widespread misuse in SVP hearings of the fake diagnosis "Paraphilia Not Otherwise Specified, nonconsent". Mental health evaluators working for the state have badly misread the DSM definition of Paraphilia and have misapplied it to rapists to facilitate their psychiatric incarceration. They have disregarded the fact that we deliberately excluded rape as an example of Paraphilia NOS in order to avoid such backdoor misuse. Not Otherwise Specified diagnoses are included in DSM only for clinical convenience and are inherently too idiosyncratic and unreliable to be used in consequential forensic proceedings.

Exclude coercive paraphilia from appendix

All along, promoters of this new diagnosis have conceded that this would be a tough sell, given its lack of scientific foundation. Indeed, they said publicly that they would consider it a victory if they could even get paraphilic coercive disorder included in the appendix of the upcoming diagnostic manual (due out in mid-2013), as a condition meriting further study. But as Dr. Frances points out, even that would be a major error:

The sexual disorders work group proposes placing "coercive paraphilia" in an appendix for disorders requiring further research. We created such an appendix for DSM IV. It was meant as a placement for proposed new mental disorders that were clearly not suitable for inclusion in the official body of the manual, but might nonetheless be of some interest to clinicians and researchers….

If "Coercive Paraphilia" were like the average rejected DSM suggestion, it would similarly make sense to park it in the appendix -- as has been suggested by the DSM 5 sexual disorders work group. This might facilitate the work of researchers and also provide some guidance to clinicians....

But "coercive paraphilia" is not the average rejected DSM diagnosis. It has been, and is continuing to be, badly misused to facilitate what amounts to an unconstitutional abuse of psychiatry. Whether naively or purposefully, many SVP evaluators continue to widely misapply the concept that rape signifies mental disorder and to inappropriately use NOS categories where they do not belong in forensic hearings.

Including "Coercive Paraphilia" in the DSM 5 appendix might confer some unintended and undeserved back-door legal legitimacy on a disavowed psychiatric construct. Little would be gained by such inclusion and the risks of promoting continued sloppy psychiatric diagnosis and questionable legal proceedings are simply not worth taking. The rejection of rape as grounds for mental disorder must be unequivocal in order to eliminate any possible ambiguity and harmful confusion. We did not include any reference to "coercive paraphilia" in DSM IV and it should not find its way in any form, however humble and unofficial, into DSM 5.

If you agree that this pseudoscientific condition needs to be placed in the wastebasket once and for all, now is the time to speak up. The current public comment period ends June 15. While you’re at it, you might want to state your opposition to a couple of the other controversial proposals with potential for profound negative consequences in the forensic realm – pedohebephilia and hypersexuality.

Postscript: Thanks to the suggestion of an alert reader, I have added the direct links to the DSM-5 comments pages. You must register in order to submit a comment.

ACH:Since you seem to keep very up-to-speed on these things, do you know the best mechanism for giving comments, as allowed through June 15? I searched around the DSM-5 website until I ran out of time, and did not find anything precisely on target. They're certainly not making it easy.

I think it's pretty much the same as before. You need to register an account--I used the one I had from the last round of commenting. Go to the disorder you want to comment on, type stuff into the box and go through about 5 rounds of their extremely annoying CAPTCHA.

There are plenty of ways of interpreting the minds of rapists as it is, without conjecturing a new 'disease'! I have met a number of these characters in the course of my forensic psychology work, and have not met one yet that was 'mad' (Twitter, @Psytac, Scotland).

I'm a defense lawyer, not a mental health professional, but adding a DMS category of a mental illness that causes people to rape raises the interesting question of whether they can be guilty of a criminal offense. If they have this mental "disorder" and it causes them to rape and the mental disorder causes them not to know their conduct is wrong, they're innocent of crimes.I wonder if the proponents have thought this through?

As a mental health clinician I find the DSM is too inclusive and no longer stands as amanual to exclude but rather include everything as a mental illness. As a Christian, I do not believe in sexual relations outside marriage and the DWM V gives me and every other Christian with the same values a diagnosis of Absexual. As a mental health clinician I find this book already includes too much - such as personality disorders - the anti socials are dangerous and should not be given a diagnosis to keep them out of gaol like it currently does. The DSM IV needs an overhaul and V should NEVER see the light of day!! I won't get started because I could go on and on. Let's suffice it to say that by including PD's - the antisocals and psychopaths not only get out of gaol, they create even more stigma for an already marginalised portion of society who I am proud to advocate for. As a result of this stigma, even news reports like today are quick to label someone as mad. Sorry but BAD does not = mad. From my experience genuine mentally ill people have all they can handle finding the motivation to get out of bed and attend to basic daily cares let alone plan terrible acts of violence. We need to start changing this NOW! Please don;t stop with this rape diagnosis - Please demand a full review and get some of these people off our books and into gaol where they truly belong. Let's stop giving them reason to muck up and send a strong message that they will NOT be able to use mental illness as an excuse. I also advocate that when a person is arrested for a crime, they should have a mental health assessment immediately. If proven not mentally unwell then they face the consequences. As for drugs/alcohol - that is a lifestyle choice not an illness. We are now beginning to reap what we sow.

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Karen Franklin, Ph.D. is a forensic psychologist and adjunct professor at Alliant University in Northern California. She is a former criminal investigator and legal affairs reporter. This blog features news and commentary pertaining to forensic psychology, criminology, and psychology-law. If you find it useful, you may subscribe to the newsletter (above). See Dr. Franklin's website for more information.

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